Formulary Listings - Jul 2011
Subject to Change Without Notice
Substitution:
Brand names are listed for reference only. We stock
many generics. Generic equivalents will be dispensed
whenever possible. Providers are encouraged to
authorize generic substitution.
Legend Medications – Maintenance medications may be
filled up to a 90-day supply with refills up to 1 year as
authorized by the prescriber. Medications for acute
conditions or medications normally taken on an as
needed basis will be limited to a 30 day supply or less
with refills as medically appropriate.
CII Medications - 30-day supply/no refills
ADHD Medications - up to 90 day supply
CIII-V Medications - 30 day supply/up to 5 refills as
authorized by the prescriber.
** Indicates a controlled substance
* Indicates quantity limit
Bold/underline indicates Basic Core Formulary
(BCF). BCF is a medication list required to be on
formulary at all full-service Military Treatment Facilities.
Abilify (Aripiprazole) 2, 5, 10, 15, 20, 30mg Tab
Absorbase (Mineral oil/pet white) oint, cream
Accolate (Zafirlukast) 20mg Tab
Activella (Estradiol/Norethindrone) 0.5/0.1 mg 28/pck
Activella (Estradiol/norethindrone) 1/0.5 mg 28/pck
Actonel (Risodronate) 5mg, 35mg and 150mg
Actos (Pioglitazone) 15, 30 & 45 mg Tab
Acular (Ketorolac Tromethamine) 0.5% opht Sol 5ml
Acular LS (Ketorolac) Opth 0.4% Solution
Adalat CC (Nifedipine) 30mg, 60mg & 90mg Tab
Adapalene (Differin) 0.1% Gel/Cr 45gm Tube
**Adderal (Amphetamine -mixed salts) 5, 10 & 20, 30mg Tab - C-II/90 day supply/No refills
**Adderal XR (Amphetamine -mixed salts) 5, 10, 15, 20, 25, 30mg Cap - C-II/90 day supply/No refills
Advair Diskus (Fluticasone/Salmeterol) 100/50mcg, 250/50mcg, 500/50mcg
Advair HFA 45-21mcg, 115/21mcg, 230/21mcg
Aerochamber (Small, Medium, and Large) w/ Mask
Aerochamber Plus
Afrin nasal spr
Aggrenox (ASA/Dipyrimamole (25/200mg Cap)
Albuterol 4mg Tab
Albuterol 2mg/5ml Syrup
Albuterol 0.5% Inhalant Soln 20ml Bottle
Albuterol 0.083mg Premixed Nebulizer Soln
Albuterol HFA 90mcg Inhaler
Alcohol Swabs (Isopropyl alcohol) 200 per box
Aldactone (Spironolactone) 25mg Tab
Aldara (Imiquimod) 5% crm
Aldomet (Methyldopa) 250mg Tab
Alesse-28/Lutera (Ethinyl Estradiol/Levonorg)
Alfuzosin (Uroxatral) 10mg Tab
Allegra (Fexofenadine) 60mg, 180mg Tab
Allegra D-12 (Fexo/Pseudo) 60mg/120mg – 20/pck
Alkeran (Melphalan) 2mg Tab
Alocril (Nedocromil) 2% Ophthalmic Sol 5ml
Alomide (Lodoxamide) 0.1% Opth Drops
Alphagan P (Brimonidine) 0.15% Opht Sol 10ml
Altace (Ramipril) 1.25, 2.5, 5, 10mg Cap
Apresoline (Hydralazine ) 25mg Tab
Alupent (Metaproterenol Sulfate) 10mg Tab
Amaryl (Glimepiride) 1mg, 2mg & 4mg Tab
** Ambien (Zolpidem) 5 & 10mg Tab
C-IV/ 30 day supply/ 5 refills max
Amicar (AminoCaproic Acid) 500mg Tab
Amitiza (Lubiprostone) 8mcg gel Cap
Amrix SR (Cyclobenzaprine) 15, 30mg Cap
Amoxil (Amoxicillin) 250, 500mg Cap, 250mg tbch
Amoxil (Amoxicillin) 875mg Tab
Amoxil (Amoxicillin) 125mg/5ml, 250mg/5ml, 400mg/5ml Susp
Amitiza (Lubiprostone) 24mcg GCP
Anaprox (Naproxen Sod) 275mg Tab
Anaprox DS (Naproxen Sod) 550mg Tab
** Androderm (Testosterone) 2.5mg, 5mg patches
**Androgel (Testosterone) 1% Pump
AnTabuse (Disulfiram) 250mg Tab
Antivert (Meclizine) 25mg Chewable Tab
Anusol-HC (Hemorrhoidal Sup/w hydrocortisone) Supp
Aphthasol (Amlexanox) 5% oral paste
Apresoline (Hydralazine) 10, 25 & 50mg Tab
1
Apriso (Mesalamine) 0.375mg Tablet
Aralen (Chloroquine phosphate) 500mg Tab
Aricept (Donepezil hydrochloride) 5mg & 10mg Tab
Aristocort Triamcinolone 0.1% Oint 15gm Tube
Aristocort A (Triamcinolone Acetonide) 0.1% Cr 15gm, 60gm
Artane (Trihexyphenidyl HCL) 2mg Tab, 0.4mg/ml sol
Artificial Tears ophthalmic soln
Asacol 400mg (Mesalamine EC) Tab
Asmanex twst (Mometasone) 110mcg, 220 mcg inh
Aspercreme (Trolamide salicylate) 10% Cr
Aspirin (Acetylsalicylic Acid) 81mg Tab
Aspirin (Acetylsalicylic Acid) 81mg chewable Tab
Aspirin EC (Acetylsalicylic Acid EC) 325mg Tab
Astelin (Azelastine) 137 mcg nasal spr
Atacand (Candesartan) 4, 8, 16, 32mg Tab
Atacand HCT (Candesartan HCT) 16/12.5, 32/12.5mg
Atarax (Hydroxyzine HCl) 10mg & 25mg, 50mg Tab
Atarax (Hydroxyzine HCl) 10mg/5ml Syrup
**Ativan (Lorazepam) 0.5mg & 1mg Tab
C-IV/30 day supply/5 refills max
Atropine Sulfate 1% Ophthalmic Sol 15ml
Atropine Sulfate 1% Ophthalmic Oint
Atrovent (Ipratropium Bromide) 0.02% Inhalant Sol
Atrovent (Ipratropium Bromide) 0.03%, 0.06% Nas Spr
Atrovent HFA (Ipratropium BR) 17gm Inhaler
Augmentin (Amox/Clavulanate) 500 & 875mg Tab
Augmentin (Amox/Clavulanate) 125/5 & 250/5 Susp
Augmentin (Amox/Clavulanate) 200/5 & 400/5 Susp
Augmentin Chew Tab (200mg amoxil/28.5mg clavulanate)
Augmentin Chew Tab (400mg amoxil/57mg clavulanate)
Augmentin ES (Amoxicillin/Clavulanic) 600mg Susp
Augmentin XR (Amox tr/pot clavul) 1,000mg Tab
Auralgan (Antipyrine/Benzocaine) 1.4/5.4% Otic Sol
Avelox (Moxifloxacin) 400mg Tab
Aygestin (Norethindrone acetate) 5mg Tab
Azasite (Azithromycin) 1% sol, 2.5ml
Azulfidine (Sulfasalazine) 500mg Tab
Bacitracin 500 U/gm Topical Ointment
Bacitracin 500 U/gm Ophthalmic Ointment
Baclofen 10mg Tab
Bactrim DS (Sulfamethoxazole/Trimethoprim) 160/800, 80/400 Tab
Bactrim (Sulfamethoxazole/Trimethoprim) 200/40 per 5ml Susp
Bactroban (mupirocin) 2% Oint, 22gm/Cr 30gm Tube
Bellergal-S (Belladonna/Phenobarb/Ergotamine) 0.2/40/0.6 Tab
Benadryl (Diphenydramine) 12.5mg/5ml Elixir
120ml,bottle (Pediatric Only), 25mg and 50mg Cap
Bentyl (Dicyclomine) 10mg Cap, 20mg Tab
Bentyl (Dicyclomine) 10mg/5ml Syrup
Benzoyl Peroxide 10% Topical Gel
Besivance 0.6% Opht drops
Betadine 10% Top Sol, 7.5% Top Soap
Betapace (Sotalol) 80mg, 120mg, 160mg & 240mg Tab
Beta-Val (Betamethasone) 0.1% Topical Cr/Lotion
Betoptic S (Betaxolol HCI) 0.25% Ophthalmic Sol 10ml
Biaxin (Clarithromycin) 125mg/5ml Susp
Biaxin (Clarithromycin) 250mg, 500mg Tab
Biaxin XL PAC (Clarithromycin) 500mg Tab
Blephamide (Sulfacetamide/prednisolone) 10%/0.2% Oint
Blephamide (Sulfacetamide/Prednisolone) 10%/0.2% Soln
Boniva (Ibandronate) 150mg
Brethine (Terbutaline Sulfate) 5mg Tab
Brevicon (Norethindrone/Ethinyl Estradiol) 0.5mg/35mcg 28 day
Buspar (Buspirone) 5mg, 10mg & 15mg Tab
Byetta (Exenatide) 5mcg/0.02ml, 10mcg/0.04ml pen injctr
Cafergot (Ergotamine tartrate) Tab
Calan (Verapamil) 80mg Tab
Calan SR (Verapamil) 120mg, 180mg & 240mg Tab
Calcium w/Vit D chewable
Capoten (Captopril) 12.5mg, 25mg, & 50mg Tab
Capozide (Hydrochlorothizide/Captopril) All strengths
Capaicin (Trixaicin) 0.025% Top Cr
Captopril 50mg, 100mg Tab
Carafate (Sucralfate) 1gm Tab
Carbachol (Isoptocarbachol) 3% Ophthalmic Sol 15ml
Carbamazepine 100mg/5ml Suspension
Cardizem (Diltiazem) 60mg Tab
Cardura (Doxazocin) 1, 2, 3, 4, 8mg Tab
Carmol-10 (Urea) 10% Lotion, 40% Cr
Casodex (Bicalutamide) 50mg Tab
*Castellani Paint (Sol 30) ml Bt – max qty 1 btl w/refills
Cataflam (Diclofenac Potassium) 50mg Tab
Catapres (Clonidine) 0.1, 0.2, & 0.3mg Tab
Catapres TTS (Clonidine) TTS-1, TTS-2, TTS-3 patches
Cefzil (Cefprozil) 250mg and 500mg Tab
Cefzil (Cefprozil) 250/5 Susp
Celebrex (Celecoxib) 100mg, 200mg Cap
Celexa (Citalopram) 10, 20, & 40mg Tab; 10mg/ml soln
Cellcept (Mycophenolate) 250mg
Cerave (Ceramides) top cr
*Cepacol lozenges Extra strength (18/box)
Cetamide (Sulfacetamide Sodium) 10% Ophth Oint/Sol
Chlorphen Maleate 4 mg Tab
2
Chlorhexidine 0.12% liq
Ciloxan (Ciprofloxacin) 0.3% Ophthlamic Oint & Soln
Ciprodex (Ciprofloxacin/Dexamethasone) Otic Drops
Cipro (Ciprofloxacin) 100mg, 250mg, 500mg, 750mg
Claritin (Loratadine) 10mg Tab
Claritin (Loratadine) 5mg/5ml Syrup
Claritin-D-24 HR (P-ephed/loratidine SR) Tab
Cleocin (Clindamycin) 300mg
Cleocin (Clindamycin) 150mg Cap
Cleocin (Clindamycin phosphate) Vag Cr 2%
Cleocin T (Clindamycin) 1% Top Sol
Climara Patches (Estradiol) 0.025, 0.05, 0.06, 0.075, .0375, 0.1mg/24 hr
Clinoril (Sulindac) 200mg Tab
*Clomid (Clomiphene Citrate) 50mg Tab (10 Tab/30 days)
Clobex (Clobetasol) 0.05% Shampoo- Restricted to Derm
**Codeine Sulfate 30mg Tab /C-II/30 day supply/No refills
CO-Enzyme Q10 (Ubidecarerone) 200mg Cap
Cogentin (Benztropine Mesylate) 0.5, 1, & 2mg Tab
Colace (Docusate Sodium) 100mg Cap
Colchicine 0.6mg Tab
Colestid (Colestipol) 1 gram Tab
Colocort (Hydrocortisone) 100mg/60ml Rectal Enema
Coly-Mycin S (1% Hydrocortisone/3.3mg Neomycin) Otic Susp
Colyte Powder for Reconstitution (PEG electrolyte sol)
Combigan (Brimonidine) 0.2%-0.5% opt drops
Combipatch (Estradiol/norethindrone) 0.05/0.14 & 0.05/0.25mg
Combivent (Albuterol/Ipratropium) Inhaler
Compazine (Prochlorperazine) 25mg Suppository
Compazine (Prochlorperazine) 5mg Tab
**Concerta (Methylphenidate) 18, 27, 36,
54mg ER Tab - C-II/90 days/no refills
Cordarone (Amiodarone) 200mg Tab
Cordran (Flurandrenoline) Tape (large) 4 mcg/sq
Coreg (Carvedilol) 3.125mg & 6.25mg Tab
Coreg (Carvedilol) 12.5mg & 25mg Tab
Coreg CR (Carvedilol 24hr) 10, 20, 40, 80mg Cap
Coricidin HBP (Dextrom/Chlor) 30mg/4mg tab
Cortef (Hydrocortisone) 20mg Tab
Cort-Enema (Hydrocortisone) 100mg/60ml Enema
Cortisone Acetate 25mg Tab
Cortisporin 1% top Ointment
Cortisporin (neomycin/polymyxin/hydrocortisone)
Opht Susp
Cortisporin (neomycin/polymyxin/hydrocortisone) Otic Susp
Cortisporin (neomycin/polymyxin/hydrocortisone) Otic Sol
Condylox (Podofilox) 0.5% Sol 60ml Bottle
Cosopt (timolol/dorzolamide) Ophthalmic Solution
Coumadin (Warfarin) 1mg & 2mg Tab
Coumadin (Warfarin) 2.5mg & 3mg Tab
Coumadin (Warfarin) 4mg & 5mg Tab
Coumadin (Warfarin) 6, 7.5, 10mg Tab
Cozaar (Losartan) 25mg, 50mg, 100mg Tab
Crestor (Rosuvastatin) 5, 10, 20, 40mg Tab
Cresylate (Cresyl/Ben/Buta/Ipa) 25% Otic Drops
Cyanobalamin (B-12) 1mg/ml Injection
Cyclogyl (Cyclopentolate) 1%, 2% Opt Soln
Cyclomydril (Cyclo/Phenyl) 0.2%/1% Opt Sol
Cytomel (Liothyronine sodium) 5, 25mcg Tab
Cytoxan (Cyclophosphamide) 50mg Tab
Dapsone 25mg Tab
**Darvocet N 100 (100 mg Propoxyphene/650 mg APAP)
Tab / C-IV/30 days/6 month max
Daypro (Oxaprosin) 600mg Tab
DDAVP (Desmopressin acetate) 0.1mg/ml Nasal Spr
Debrox (Carbamide Peroxide) ear drop 15 ml
Decadron (Dexamethasone) 0.75mg & 4mg Tab
Decadron (Dexamethasone) 0.5mg/5ml Elixir
Delsym (Dextromethorphan) 30mg/5ml susp
Deltasone (prednisone) 1mg, 5mg, 10mg & 20mg Tab
5mg/5ml sol
**Demerol (Meperidine) 50mg Tab C-II/30 days/no refills
Demulen 1/35 (thynodiol diacetate/ethinyl estradiol) 28 day pk
Depakene (Valproic acid) 250mg/5ml Syrup
Depakote ER (Divalproex) 250, 500mg Ext Rel Tab
Depakote (Divalproex Sodium DR) 125, 250 & 500mg
Depakote (Divallproex Sodium) 125mg sprinkles Cap
Depo-Provera Vial (Medroxyprogesterone Acetate) 150mg/dose - C-V/30 days or 1 vial/5 refills max
**Depo-Testosterone Inj 200mg/ml 1ml multidose vial
Derma-Smooth/FS (Fluocinolone Acetonide) 0.01% Top Oil
Desowen (Desonide) .05% Cr 15gm Tube
Desowen (Desonide) .05% Lotion 120ml Bottle
Desquam (Benzoyl Peroxide) 5%, 10% topical soap
Desyrel (Trazodone) 50mg, 100mg, 150, 300mg Tab
Detrol LA (Tolterodine Tartrate) 2mg & 4mg Cap
**Dexedrine Spansule (Dextroamphetamine) 5mg Tab, 10mg &15mg CPSR, C-II/90 day supply/no refills
Diamox (Acetozolamide) 250mg Tab
Diamox SR (Acetozolamide) 500mg Sequels
Diaphragm Kit 60, 65, 70, 75, 80, 85, 90
Diflucan (Fluconazole) 100mg, 200mg Tab
Diflucan (Fluconazole) 150mg Tab (Vag Candidiasis Only)
Dilantin (Phenytoin) 100mg Cap “Parke Davis Brand”
Dilantin (Phenytoin) 125mg/5ml Susp “Parke Davis Brand”
3
Dilantin (Phenytoin) 50mg Chew Tab “Parke Davis Brand”
**Dilaudid (hydromorphone) 2mg Tab
C-II/30 day supply/no refills
Diovan (Valsartan) 40mg, 80mg, 160mg, 320mg Tab
Diovan HCT (Valsartan HCTZ) 80-12.5mg, 160-25mg ,
320-12.5mg, 320-25mg Tab
Disalcid (Salsalate) 500mg, 750mg Tab
Ditropan (Oxybutynin) 5mg Tab
Ditropan (Oxybutynin) 5mg/5ml Elixir
Ditropan XL (Oxybutynin chloride) 5, 10, 15mg tab
**Dolophine (Methadone HCL) 5mg, & 10mg Tab
C-II/30 day supply/no refills
Domeboro (Aluminum acetate) Otic Sol
Domeboro Pkt Powder (Calcium Acet/Alum Sulf)
Donnatal (Belladonna alkaloids/phenobarbital) Tab
Donnatal (Belladonna alkaloids/Phenobarbital) Elixir 120ml Bt
Doryx (Doxycycline Hyclate) 100mg,150mg delayed release Tab
Dovonex (Calcipotriene) .005% Cr and Solution
Doxepin HCL 10, 25, 50, 75mg Tab, 10mg/ml Suspension
Drysol (Aluminum chloride) 20% Sol 30ml Bt
Duac Top (Clindamycin/Benzoyl perox) Gel
Dulcolax (Bisacodyl) 5mg Tab, 10ng suppositories
Dulera (Mometasone/Fomoterol) 100mcg/5mcg and
200mcg/5mcg inhaler
Duoneb (Ipratropium/Albuterol) 0.5-3mg/3 inh sol
Duricef (Cefadroxil) 125mg/5ml & 250mg/5ml Susp
Dynapen (Dicloxacillin sodium) 250mg & 500mg Cap
EES (Erythromycin ethylsuccinate) 200mg/5ml Susp
Effexor XR (Venlafaxine) 37.5mg, 75mg & 150mg Cap
Effexor 100mg (Venlafaxine) Tab
Efudex (Fluorouracil) 5% Cr 40gm Tube
Elavil (Amitriptyline) 10mg, 25mg, 50mg & 75mg Tab
Eldepryl (Selegiline) 5mg Tab
Eldoquin Forte (Hydroquinone) 4% Cr 30gm Tube
Elestat 0.05% opth sol (Elesol Epinastine HCL)
Elidel (Pimecrolimus) Cr 30gm Tubes
Elmiron (Pentosan polysulfate) 100mg Cap
Elimite (Permethrin) 5% Cr
Enablex (Darifenacin hydrobromide) 7.5 and 15mg Tab
Enema Disp Liq (SOD phosphate/SOD/Biphos) 4.5 oz
Epifrin (Epinephrine HCL) 1% Ophthalmic Sol
Epi-Pen (Epinephrine) .3 mg Auto Injector Pen
Epi-Pen Jr. (Epinephrine) .15mg Auto Injector Pen
Epinephrine (Twinjet)
Eryderm (Erythromycin) 2% Solution 60ml Bt
Erygel (Erythromycin) 2% topical gel
Erythromycin BASE (Erythromycin) 250mg Tab
Erythromycin Ophthalmic Ointment
Eskalith (Lithium Carbonate) 300mg Cap
Eskalith CR (Lithium Carbonate) 450mg TB
Estradiol 0.25, 0.75, 1mg/24hr, 37.5mcg/24hr
0.025, 0.05, 0.06, 0.075, 0.1, 0.0375mg
Estratest (1.25mg esterified estrogen /2.5mg
methyltestosterone) Tab
Estratest HS (0.625mg estrogen /1.25mg methyltestosterone) Tab
Estring (Estradiol) 2mg Vaginal Ring
Evista (Raloxiphene) 60mg Tab
Exelon (Rivastigmine) 4.6mg/24 hr, 9.5mg/24hr Patch
E-Z Spacer
Feldene (Piroxicam) 20mg Cap
Fenofibrate 54mg, 160mg Tab
Ferrex 150 Plus (Iron, Vit C, Succinic Acid) Capule
Ferrous Sulfate 325mg Tab
Ferrous Sulfate 220mg/5ml Liquid
Ferrous Sulfate (Fer-Iron) 15mg/ml Oral Drop
Finacea (Azelaic acid) gel top 15%
Restricted to Dermatologist (Mil & Civ)
Fioricet (Butalbital/caffeine/APAP) 50/40/325 Tab
**Fiorinal (Butalbital/caffeine/aspirin) 50/40/325 Tab
C-IV/30 days/6 month max
First-Mouthwash Blm 25-200/30 - Soln
Fish Oil 1000mg Cap
Fibercon (Polycarbophil) 625mg Tab
Flagyl (Metronidazole) 250mg & 500mg Tab
Flagyl (Metronidazole) 0.75% vaginal gel
Flector Patch (Diclofenac) 1.3%
Fleet Enema (Sodium phosphate) 133ml
Fleet Enema (Sodium phosphate) pediatric 65/ml
Fleet Phospo-Soda oral sol/bt unflavor 36 x 1.5 oz
Flexeril (Cyclobenzaprine) 5, 10mg Tab
Flomax (Tamsulosin) 0.4mg Cap
Flonase (Fluticasone) 0.05% Nasal Inhaler
Florinef (Fludrocortisone acetate) 0.1mg Tab
Flovent (Fluticasone) Diskus 50, 100 & 250mcg/blister
Flovent (Fluticasone) HFA44mcg, 110mcg & 220mcg Inhaler
Floxin (Ofloxacin) Otic Drops 0.3% 5ml
Fluoride Sodium 1mg Tbch
FML (Fluorometholone) 0.1% Ophthalmic Susp & Oint
Folic Acid 1mg Tab
Foradil (Formoterol) 12mcg inhaler Cap/dev
Fosamax (Alendronate) 5mg, 10mg, 35mg & 70mg Tab
Fosamax (Alendronate) 70mg/75ml soln
4
Fosamax PlusD (Alendronate/cholecalciferol)
70mg/2,800 units, 70mg/5600mg units
Fungoid Tincture top 2% soln
Furadantin (Nitrofurantoin) 25mg/5ml Susp
Garamycin (Gentamicin) 0.1% Topical Cr and ointment
Garamycin (Gentamicin sulfate) 3mg/ml Opht Sol
Garamycin (Gentamicin sulfate) 3mg/gm Opht Oint
Geodon (Ziprasidone HCl) 20mg, 40mg, 60mg & 80mg Cap
Glucagon Inj 1mg kit
Glucophage (Metformin) 500mg, 850mg, & 1000mg
Glucophage (Metformin) XR 500mg, 750mg Tab
Glucose dextrose 40% oral gel (Glutose) 37.5gm tube
Glucotrol (Glipizide) 5mg 10mg Tab Immediate Release
Glucotrol XL (Glipizide) 2.5mg, 5mg & 10mg Tab
Glucovance (Glyburide/metformin) 1.25/250mg, 2.5/500mg & 5/500mg Tab
Glynase PresTab (Micronized glyburide) 1.5, 3 & 6mg Tab
Gris-Peg (Ultramicrosized griseofulvin) 125mg, 250mg Tab
Gris-Peg (Griseofulvin) 125/5 Susp
Guaifenesin 400 mg Tab
Half-lytely powder + bisacodyl Tab
Hibiclens (Chlorhexidine Gluc) 4% Top Liquid
Homatropine 5% Ophthalmic Sol 15ml
*Humira Pen/Syr (Adalimumab) 40mg/0.8ml inj
30 day supply with refills
Hydrea (Hydroxyurea) 500mg Cap
Hydrochlorothiazide 12.5mg, 25mg & 50mg Tab
Hydrocortisone 1% Cr / 2% Lotion
Hygroton (Chlorthalidone) 50mg Tab
Hytrin (terazosin) 1mg, 2mg, 5mg & 10mg Cap
Hyzaar HCTZ (Losartan/HCTZ) 50-12.5mg,
100-12.5mg, 100-25mg Tab
Icy Hot (Methyl Salicylate/menthol) Top Cr
Ilotycin (erythromycin) 5% Ophthalmic Oint
Imdur (Isosorbide mononitrate) 30mg, 60mg, 120mg Tab
*Imitrex (Sumatriptan) Stat dose kit
*Imitrex (Sumatriptan) 6mg/0.5ml Syringe 4 units p/30 days
*Imitrex (Ssumatriptan) 20mg, 5mg Nasal Spr 6 p/30 day
* Imitrex (Sumatriptan) 25, 50, 100mg Tab
Imodium (Loperamide) 2mg Cap
Imuran (Azathioprine) 50mg Tab
Inderal LA (Propranolol) 60mg, 80mg, 120mg & 160mg Cap
Indocin (Indomethacin) 25mg & 50mg Cap
Inspirease Replacement Bags 3 bags/Box
Inspirease Kit with 3 bags
Iopidine (Apraclonidine) 1% Opth Soln
Ismo 20mg (Isosorbide Mononitrate Tab
Isoniazid (INH) 100mg & 300mg Tab
Isoniazid (INH) 50mg/5ml Syrup
Isopto-Cetapred (Sulfacetamide) 10% Ophthalmic Sol
Isopto-Cetapred (Sulfacetamide) 10% Ophthalmic Oint
Isopto-Hyoscine (Scopolamine hydrobromide) 0.25% Sol
Isordil (Isosorbide dinitrate) 5, 10, 20 & 30mg Tab
Isordil (Isosorbide dinitrate) 40mg ER Tab
Janumet (Sitagliptin phos/metform) 50/500mg, 50/1000mg
Januvia (Sitagliptin phos) 25, 50, 100mg Tab
Kayexlate (Sodium polystyrene) 15gm/60ml Susp
K-Dur (Potassium chloride) 10meq & 20mEq Tab
Keflex (Cephalexin) 250 & 500mg Cap; 250mg/5ml susp
Kenalog (Triamcinolone acetonide) 0.1% Top Spr 63gm
Kenalog (Triamcinolone) 0.1% Cr 15gm Tube
Kenalog (Triamcinolone) 0.1% Oint 15gm Tube
Kenalog in Orabase (Triamcinolone acetonide) Oral Paste
Keppra (Levetiracetam) 250, 500, 750mg Tab, 100mg/ml sol
Ketoconazole 2% crm 30gm
**Klonopin (Clonazepam) 0.5mg, 1mg Tab
C-III/30 day supply/6 month max
Klor-Con (Potassium CHL) 8Meq TBSR
Lac-Hydrin (Ammonium Lactate) 12% Lotion /Cr
Lactulose 10mg/15ml Syrup
Lamictal (Lamotrigene) 25, 100, 150, 200mg Tab
Lamictal ODT (Lamotrigine ODT) 100, 200mg Tab
Lamisil (Terbinafine) 250mg Tab and 1% Cr
Lancets 100 per box
Lanoxin (Digoxin) 0.125 & 0.25mg Tab
Lanoxin (Digoxin).05mg/1ml Sol Brand Name Only 60ml
Lantus (Insulin glargine) 10ml Bottle
Lantus Solo (Insulin glargine) 100u/ml PFS 5x3 ml
Lariam (Mefloquine) 250mg Tab
*Lasix (Furosemide) 10mg/ml Sol, 60 ml bottle
Lasix (Furosemide) 20mg & 40mg Tab
Leukeran (Chlorambucil) 2mg Tab
Leuprolide kit (Lupron depot) 11.25mg SolR
*Levaquin (Levofloxacin) 250mg, 500mg & 750mg Tab
Levaquin (Levofloxacin) 25mg/ml soln
Levemir (Detemir) insulin Flexpen
Levemir vials (Detemir) 100 units /10ml vials
*Levitra (Vardinifil) 5, 10, 20mg Tab - 6 Tab per month
Note: Only for pts 40 yrs of age and over
Levsin SL (Hyoscyamine) 0.125mg Tab
Librax (Chlordiazepoxide) 5/2.5mg Cap
**Librium (Chlordiazepoxide) 5, 10mg Cap - C-IV/30 day
Lidex E (Fluocinonide) 0.05% Cr 15gm Tube
5
Lidex (Fluocinonide) 0.05% Oint 15gm tube; 0.05% Cr
Lithium Citrate 8meq/5ml soln
Lidex (Fluocinonide) 0.05% Gel 15gm Tube
Lidex (Fluocinonide) 0.05% Top Sol – 60ml/bt
**Lidocaine (Lidoderm) 5% , 700mg, Top Ptch - 5 refills
Lipitor (Atorvastatin) 10mg, 20mg, 40mg, 80mg Tab
Loestrin Fe 1.5/30 (norethindrone/ethinyl estradiol) 28 days
Loestrin Fe 1/20 (norethindrone/ethinyl estradiol) 28/ds
**Lomotil (Dphenoxylate)/ 2.5mg Tab
C-IV/30days supply/5 refills max
Loniten (Minoxidil) 2.5mg, 10mg Tab
Lo/Ovral (0.3mg norgesterol/30mcg Ethinyl Estradiol)/28/ds
Lopid (Gemfibrozil) 600mg Tab
Lopressor (Metoprolol) 25mg 50mg 100mg Tab
**LorTab (Hydrocodone/APAP)2.5mg-167mg/5ml elixir
C-III/30 day supply/5 refills max
Lotemax 0.5% Opht susp
Lotensin (Benazepril) 5mg, 10mg, 20mg & 40mg Tab
Lotensin HCT (Benazepril/HCTZ) 5mg/6.25mg Tab
Lotensin HCT (Benazepril/HCTZ) 10mg/12.5mg Tab
Lotensin HCT (Benazepril/HCTZ) 20mg/12.5mg Tab
Lotensin HCT (Benazepril/HCTZ) 20mg/25mg Tab
Lotrel (Amlodipine/benazepril) 2.5/10, 5/10, 5/20, 5/40,
10/20, 10/40mg Cap
Lotrimin (Clotrimazole) 1% Cr, soln
Lotrisone (Clotrim/Beta) 1/0.05% Cr
Lovenox (Enoxaparin Sodium) 30, 40, 60, 80, 100mg
No refills
Lovaza (Omega-3) 1gm Cap
Lozol (Indapamide) 1.25mg & 2.5mg Tab
Lumigan (Bimatoprost) 0.03% Ophthalmic drops
**Lunesta (Eszopiclone) 1, 2, 3 mg Tab C-IV/30 day
supply/5 refills max
Lupron Depot (Leuprolide acetate) 3.75mg & 7.5mg Inj
Lupron Depot (Leuprolide acetate) 22.5mg Injection
Luride (Sodium fluoride) 2.2mg Tab
Luvox (Fluvoxamine) 50mg & 100mg Tab
Macrobid (Nitrofurantoin macrocrystals) 100mg Cap
Macrodantin (Nitrofurantoin macrocrystals) 50mg & 100mg
Magnesium Citrate – regular liq 10oz
Magnesium Oxide (Magox) 400mg Tab
Matulane (Procarbazine) 50mg Cap
*Maxalt (Rizatriptan) 5mg, 10mg Tab- 18 Tab per 30 ds
*Maxalt MLT (Rizatriptan) 5, 10mg Tab – 18 Tab per 30 ds
Maxzide (HCTZ/Triamterene) 50/75mg Tab
Maxzide-25 (HCTZ/Triamterene) 25/37.5mg Tab
Mediplast 40%/salisylic acid
Medrol (Methylprednisolone) 4mg Tab & Dosepak
Megace (Megestrol acetate) 40mg Tab
Mephyton Pytonadione (Vitamin K) 5mg Tab
Mestinon (Pyridaostigmine bromide) 60mg Tab
Metamucil (Psyllium/sucrose)
Methadone 5mg, 10mg Tab
Methergine (Methylergonovine maleate) 200mcg Tab
Methotrexate 2.5mg Tab
MetroCr (Metronidazole 0.75%, 45g)
Metrogel (Metronidazole) 1% top; vag Gel 45gm Tube
Mexitil (Mexilitine) 150mg
Micardis (Telmisartan/) 20mg, 40mg, 80mg
Micardis HCT (Telmisartan hydrochlorothiazide)
40/12.5mg, 80/12.5mg, 80/25mg
Miochol E (Acetylcholine Chloride) 20mg Opth Sol
Mircette 28 days Tab
Micronase (Glyburide) 1.25mg, 2.5mg and 5mg Tab
Minocin (Minocycline) HCL 50mg & 100mg Cap
Miralax Pwd (Polyethylene glycol) 255gm, 527 gm
Mirapex (Pramipexole) .125, .25, .0.5, 1.5, 1mg Tab
Mircette 28 days (birth control)
Micronor (norethindrone) 0.35mcg 28 day cycle
Minipress (Prazosin) 1mg, 2mg & 5mg Cap
Mobic (Meloxicam) 7.5mg & 15mg Tab
Monistat 3 Combo Pck (supp/Cr)
Monoket (Isosorbide Mononitrate) 10mg Tab
Monopril (Fosinopril) 10mg & 20mg Tab
**Morphine Sulfate10mg/5ml Sol
C-II/30 day supply/no refills
*Motrin (Ibuprofen) 100mg/5ml Susp (Pediatric Only)
Motrin (Ibuprofen) 400mg, 600mg & 800mg Tab
**MS Contin (morphine sulfate) 15mg, 30mg, 60mg, & 100mg - C-II/30 day supply/no refills
** MSIR (Morphine sulfate) 15mg & 30mg (immediate rel) Tab - C-II/30 day supply/no refills
Mucinex (Guaifenecin SA) 600mg Tab
Mucinex DM (Guafenesin DM) 600/30 Tab - 40/Box
Mucinex D(Guai/Pseu) 600/60 TBSR - 18/Box
Mucinex MM Child (Guaifenesin) 50mg - 12/Box
Mucus Relief (Guafenesin) 400mg Tab
Mucomyst (Acetylcysteine) 20% Inhalant Soln
Multaq (Dronedarone) 400mg
Multivitamins Tab and chewables
Muro-128 (Sodium Chl) 5% Opth Oint, Sol
Myambutol (Ethambutol) 100 & 400mg Tab
Mycelex (clotrimazole) 10mg Troches, 1% Cr/15gm
Mycifradin (neomycin sulfate) 500mg Tab
6
Mycolog II (nystatin/triamcinolone) Cr
Myleran (busulfan) 2mg Tab
Mysoline (primidone) 50mg & 250mg Tab
Naftin (naftifine) 1% Cr/Gel
Naprosyn (Naproxen) 250 & 500mg Tab; 125mg/5ml susp
Nasonex 50mcg nasal spr 17gm (mometasone)
Neomycin/polymyxin/gramicidin opth soln
Neomycin/ploymyxin/hydrocortisone
Neosporin (neomy/polymyx/bacitracin) Opth Sol/top oint
Neptazane (methazolamide) 50mg Tab
Neurontin (gabapentin) 100mg, 300mg & 400 Cap
Neurontin (gabapentin) 600mg & 800mg Tab
Nevanac (Nepafenac opth) susp 0.1%
Nexium (Esomeprazole) 20, 40mg Cap
Nexium (Esomeprazole) 10, 20, 40 Suspension - 30/pck
Niaspan (Niacin) 500mg, 750mg & 1000mg Tab SR
Nilandron (nilutamide) 150mg Tab
Nitro-BID (nitroglycerin) 6.5mg & 9mg Cap SR
Nitro-Dur (Nitroglycerin) 0.2, 0.4, 0.6mg patch
Nitrol (Nitroglycerin) 2% Oint 60 gram tube
Nitrospr (Nitroglycerin) 400mcg/spr Spr
Nitrostat SL (Nitroglycerin) 0.4mg Sublingual Tab
Nizoral (Ketoconazole) 200mg Tab
Nizoral (Ketoconazole) 2% Shampoo
Nix Crm Rinse (Permethrin) 1% - 2oz
Nolvadex (Tamoxifen citrate) 10mg, 20mg Tab
Nonoxynol 9 (Shur-Seal) Vag 2% gel
Nordette 28 – 0.15/0.03 (levonorgestrel/ethin)
Norflex (Orphenadrine) 100mg Tab
Norgesic Forte (Orphenadrine/ASA/Caffeine) 50/770/60 Tab
Norlutate (Norethindrone acetate) 5mg Tab
Normodyne (Labetolol) 100mg & 200mg Tab
Norpace (Disopyramide) 100mg & 150mg Cap Reg Rel only
Norvasc (Amlodipine) 2.5mg, 5mg, 10mg Tab
Novofine 30 (Needles, ins) 100/box
Novolin 70/30 (Insulin NPH/Reg HM) Vial
(NOTE: not the same as NovoLog 70/30)
Novolin R (Insulin R) 100/ml vial
Novolin N (Insulin N NPH) 100ml/vial
Novolog Flx Pen (insulin aspart) 10ml Bottle
Novolog Mix Flex Pen 70/30 vial
Novolog (insulin Aspart) 10ml Bottle
NovoLog Mix (Aspart/Human) 70/30 10ml Bottle
(NOTE: not the same as Novolin 70/30)
Nuvaring vag ring (Etonogestrel ethinyl estradiol)
**Nuvigil (Armodafinil) 50, 150, 250mg Tab
Nystatin (Mycostatin) 500,000units Tab
Nystatin (Mycostatin) 100,000units/gm Susp and Cr
Nystatin (Mycostatin) 100,000units/gm Powder 60ml Bottle
Ocufen (Flurbiprofen) 0.03% Ophthalmic Sol 2.5ml
Ocuflox (Ofloxacin) 3mg/ml Ophthalmic Sol 5ml
Ocupress (Carteolol) 1% Ophthalmic Sol 10ml
Ocusoft Lid top kit
Ocean (Sodium Chloride) 0.65% NAS Spr
Ogen (Estropipate) 0.75mg &1.5mg Tab
Olux (Clobetasol) 0.05% foam
Olux E (Clobetasol prop/emoll 0.05% foam
Omnicef (Cefdinir) 125mg/5ml, 250mg/5ml suspension
Omnicef (Cefdinir) 300mg Cap
OptiPranolol (Metipranolol) 0.30% Ophthalmic Sol
Oracea (Dosycline monohydrate) 40mg Cap
Orapred ODT (Orapred Prednisolone) 10, 15, 30mg TBSL
Orapred (Prednisolone/So/Phos) 15mg/5ml solution
Ortho-Cept (desogestrel/ethinyl estradiol) 0.15mg/30mcg
Ortho-Cyclen (ethinyl estradiol/norgestimate) 35mg/0.25mg Tab
Ortho-Evra (norelgestromin/Ethinyl Estradiol) Weekly Patch
Ortho-Gynol (nonoxyl-9) Contraceptive Gel
Ortho-Novum 1/35 (1mg norethindrone/35 mcg ethinyl estradiol)
Ortho-Novum 1/50 (1mg norethindrone/50 mcg ethinyl estradiol)
Ortho-Novum 777 (norethindrone/ ethinyl estradiol)
Ortho Tri-Cyclen (norgestimate/ethinyl estradiol) 28 day pck
Ortho Tri-Cyclen Lo (norgestimate/ethinyl estradiol) 28 day pck
Orudis (Ketoprofen) 75mg Cap
Oscal 500 plus D (Caldium & vitamin D) 500mg Tab
Osmoprep Tablets
Osteobiflex (Glucosamine/Chondroitin) 500mg/400mg Cap
**Oxycodone HCL 5mg Tab – limit of 60 Tab
** Oxycontin (Oxycodone ER) 10, 20mg Tab – limit/20 Tab
Pamelor (Nortriptyline HCL) 10mg & 25mg, 50mg Cap
10mg/5ml sol
Pancreaze DR 4.2k-10k, 10.5k-25k, 16.8-40-70k, 21-37-61k Cap
Panoxyl (Benzoyl peroxide) Top 10% gel, 1.5oz
Paraguard T-380-A intra uterine device (IUD)
Parlodel (Bromocriptine mesylate) 2.5mg Tab
*Patanol (Olopatadine) 0.10% Opht Sol /2 units per month
Paxil (Paroxetine) 10mg, 20mg Tab
Penlac (Ciclopirox) 8% Top Soln
Pen VK (Penicillin V – Potassium) 250mg & 500mg Tab
Pen VK (Penicillin V – Potassium) 125mg/5ml, 250/5 Susp
Pepcid (Famotidine) 20mg, 40mg Tab
Pepcid (Famotidine) 40mg/5ml Suspension
Pepto Bismol (Pink Bismuth) Tab
7
**Percocet (Oxycodone/APAP) 5mg/325mg Tab
C-II/30 day supply/no refills
Periactin (Cyproheptadine) 4mg Tab; 2mg/5ml syr
Peridex (Chlorhexidine gluconate) 0.12% Mouth Rinse
Persantine (Dipyridamole) 25mg & 75mg Tab
Petrolatum (Vaseline) 30gm tube
Phenergan (Promethazine) 25mg Tab
Phenergan (Promethazine) 12.5mg and 25mg Supp
Phenergan (Promethazine) 6.25mg/5ml Syrup
**Phenobarbital 15, 30, 60, 100mg Tab -C-IV /30 days / 6
month max
**Phenobarbital 20mg/5ml Elixir -C-IV/90days/6mth max
Phospholine Iodine 0.06% Sol
Pilocarpine 1%, 2% and 4% Sol 15ml
Pilocarpine 4% Ophthalmic Gel
Pill Cutters
Pill Planner weekly
Plaquenil (Hydroxychloroquine) 200mg
Plan B (Levonorgestrel) 0.75mg
Plavix (Clopidogrel) 75mg Tab
Plendil (Felopidine) 2.5mg, 5mg & 10mg Tab
Plexion cloths (Sulfur/sulfacetamide) limited/1 month
Polycitra-K Crystals powder
Polysporin (Polymixin B/bacitracin) 10000u/500u Opht Oint
Polytrim (PpolymixinB/trimethoprim) 10000u/1mg Opht Sol
Poly-vi-sol (Multivitamin) Soln
Ponstel (mefenamic acid) 250mg Cap
Pradaxa (dabigatran) 150mg Cap
Pravachol (pravastatin) 10mg, 20mg, 40mg, & 80mg Tab
Precision Extra Monitor Blood Glucose Monitor
*Precision Extra Test Strips - Max of 400 strips for 90 days
Pred Forte (Prednisolone acetate) 1% Ophthalmic Susp 10ml
Pred Mild (Prednisolone acetate) 0.12% Susp
Prelone (Prednisolone acetate) 15mg/5ml Syrup
Premarin (Conjugated estrogens) 0.45, 0.625, 0.3, 0.9, 1.25mg Tab
Premarin (conjugated estrogens) 0.625mg/gm Vaginal Cr
Prempro (Estrogen/Medroxyprogeterone) 0.3/1.5mg, 0.45/1.5mg, 0.625/2.5mg, 0.625/5mg Tab
Prenatal Vits (pregnant, lactating women or
45 years or younger)
Prenatal Vits with DHA
Prevident 5000 PLUS (Sodium Flouride) Dental Paste
Prilosec (Omeprazole) 10mg, 20mg
Primaquine Phosphate 26.3mg Tab
Prinivil (Lisinopril) 2.5gm, 5mg, 10mg, 20mg & 40mg Tab
Probenecid 500mg Tab
Procan SR (Procainamide) 500mg Tab
Proctofoam-HC (Pramoxine/hydrocortisone) Rectal Foam
Procto-zone (Hydrocortisone) 2.5% Rectal Cr
Prometrium (Progesterone) 100, 200mg Cap
Propylthiouracil (PTU) 50mg Tab
Proscar (Finasteride) 5mg Tab
Protopic (Tacrolimus) .03%, 30gm, 0.1%, 30 & 60gm oint
Provera (Medroxyprogesterone) 2.5mg, 5mg & 10mg Tab
** Provigil (modafinil) 100 & 200mg Tab C-IV/30
day supply/5 refills max
Prozac (Fluoxetine) 10, 20, & 40mg Cap; 20mg/5ml soln
Pulmicort Respules (Budesonide) 0.25mg/2ml & 0.5mg/2ml Inh Susp
Pulmicort respules (Budesonide) 1mg/2ml
Purinethol (MerCaptopurine) 50mg Tab
Pyrazinamide 500mg Tab
Pyridium (Phenazopyridine) 100mg, 200mg Tab
Pyridoxine (B-6) 50mg Tab
Questran Light (Cholestyramine) 4gm/scoop powder
Refresh opt drp (Polyvinyl alc/povidone) tears
Refresh Celluvisc opth drops
Refresh PM opt oint (Lubrifresh) 3.75 gms
Reglan (Metoclopramide) 10mg Tab
Reglan (Metoclopramide) 5mg/5ml Syrup
Relafen (Nabumetone) 500mg, 750mg Tab
Remeron (Mirtazapine) 15mg, 30mg, & 45mg Tab
Restasis (Cyclosporine) 0.05% Opt Sol
**Restoril (Temazepam) 15mg & 30mg Cap
C-IV/30 day supply/5 refills max
Requip (Ropinirole) 0.25, 0.5, 1, 2, 3, 4mg Tab
Requip XL (Ropinirole) 2, 4, 6, 8, 12mg Tab
Retin A: Limited to beneficiaries age 35 or younger
*Retin-A (Tretinoin) 0.025% Cr 45gram Tube
*Retin-A (Tretinoin) 0.05% Cr 20gram tube
*Retin-A Micro (Tretinoin) 0.04% and 0.1% gel
Ridaura (Auranofin) 2mg Cap
Rifadin (Rifampin) 300mg Cap
Risperdal (Risperidone) 0.25, 0.5, 1, 2, 3, 4mg Tab, 1mg/ml syr
Risperdal (Risperidone) 1mg/1ml solution
**Ritalin (Methylphenidate) 5mg, 10mg, & 20mg Tab
CII/90 day supply/no refills
**Ritalin-SR (Methylphenidate) 20mg Sustained Release Tab - CII/90 day supply/no refills
Robaxin (Methocarbamol) 500mg Tab
Robitussin (Guaifenisen) Syrup 100mg/5ml
**Robitussin AC (Guaifensin/codeine)l Syrup Bts of 120ml
CV/30 day supply/5 refills max
Robitussin DM (Guaifensin/DM) 100mg/10mg in 5mlr
Rocaltrol (Calcitrol) 0.25mcg Cap
8
Rowasa (Mesalamine) Enema
**Roxicet (Oxycodone) Elixir 5-325/5ml
Rythmol (Propafenone) 150mg & 300mg Tab
Santyl (Collangenase) Oint
Scopolamine Hbr (Hyoscine HBr) 15ml Oph Sol
Selsun Shampoo (Selenium sulfide) 2.5%
Senokot S (DOK Plus ) 8.6/50mg Tab
**Serax (oxazepam) 15mg Cap\
CIV/30 day supply/5 refills max
Serevent Diskus (Salmetrol) 50mcg Inhaler
Serophene (Clomiphene citrate) 50mg Tab
Seroquel (Quetiapine) 25, 50, 100, 200, 300, 400mg, Tab
Seroquel XR (Quetiapine) 50, 150, 200, 300, 400mg Tab
Silvadene (Silver sulfadiazine) Cr 20gm, 85gm &400gm Tab
Simethicone 40mg/0.6ml Suspension
Sinemet (Carbidopa/levodopa) 10/100mg & 25mg/100mg Tab
Sinemet (Carbidopa/levodopa) 25mg/250mg Tab
Sinemet CR (Carbidopa/levodopa) 50mg/200mg & 25mg/100 Tab
Singulair (Montelukast) 10mg Tab
Singulair (Montelukast) 4mg & 5mg Chewable
Singulair (Montelukast) 4mg Oral Granules
Slow-K (Potassium chloride) 8mEq Tab SR
Skelaxin (Metaxalone) 400mg & 800mg Tab
Sodium Chloride 0.9% Inhalation Sol 5ml Amp
Solodyn ER (Minocycline HCL) 65mg Tab
Spiriva 18mcg (Tiotropium bromide Cap w/dev)
Strattera (Atomoxetine) 10mg, 18mg, 25mg, 40mg & 60mg Cap
*Sudafed (Psuedoephedrine) 30mg Tab (1 box per month)
Sudafed (Psuedoephedrine) 30mg/5ml Liq (Pediatric Only)
Sulfacetamide Sodium 10% Sol
Suprax (Cefixine) 400mg Tab
Symbicort (Budesonide/Formoterol) 80/4.5mcg, 160/4.5mcg Inh
Symmetrel (Amantadine) 100mg Cap
Synalar (Fluocinolone acetonide) 0.01% Sol 60ml Bt
Synalar (Fluocinolone acetonide) 0.025% Cr 15gm Tube
Synthroid Brand Only
Synthroid+ (Levothyroxine) 0.025mg & 0.05mg Tab
Synthroid+ (Levothyroxine) 0.075mg & 0.088mg Tab
Synthroid+ (Levothyroxine) 0.1mg & 0.112mg Tab
Synthroid+ (Levothyroxine) 0.125mg & 0.175mg Tab
Synthroid+ (levothyroxine) 0.15mg & 0.137mg Tab
Synthroid+(Levothyroxine) 0.2mg & 0.3mg Tab
*Syringes (Insulin) 0.5cc, 0.3cc & 1cc Max 600- 90 days
Syringes: TB for B-12 shots
Taclonex (betamet diprop/calcipotriene) oint 60gms/.005%
Restricted to DERMATOLOGIST (MIL or CIV)
Tagamet (Cimetidine) 400mg Tab
Tambocor (Flecainide) 100mg Tab
Tamiflu (Oseltamivir) 75mg Cap, 12mg/ml suspension
Tapazole (Methimazole) 5mg Tab
Tazorac (Tazarotene) top crm 0.1%, 30gms tube
Tegretol (Carbamazepine) 200mg Tab; 100mg/5ml susp
Tegretol (Carbamazepine) 100mg Chewable Tab
Tekturna (Aliskiren) 150mg, 300mg Tab
Tekturna HCT (aliskiren/HCTZ) 150/12.5mg, 150/25mg
Tekturna HCT (aliskiren/HCTZ) 300/12.5mg, 300/25mg
Temovate (Clobestasole) 0.05% Oint 60gm, 0.05% gel 60gm, 0.05% soln 60gm
Temovate-E (Clobestasole) 0.05% Emollient base Cr 60gm
Tenormin (Atenolol) 25mg, 50mg & 100mg Tab
Tenoretic (Chlorthalidone/atenolol) All strengths Tab
Terazol-3 (Terconazole) Vaginal Cr 0.8%, 20gms
Terazol-7 (Terconazole) Vaginal Cr 0.4%, 45gms
Tessalon (Benzonatate) 100mg Cap
Tetracycline 250mg Cap
Thalitone (Chlorthalidone) 25 & 50mg Tab
TRUERESULT blood glucose monitor
TRUE2GO blood glucose meter
Trusopt (Dorzolamide) 2% Sol 10ml
T-Stat (Erythromycin) 2% Sol 60ml Bottle
Twinject (Epinephrine) 0.15mg/0.15ml, 0.3mg/0.3ml
*Tylenol (Acetaminophen) 80mg/0.8ml Drops (Peds Only)
*Tylenol (Acetaminophen) 160mg/5ml Sol (Peds Only)
Tylenol (Acetaminophen) 325mg Tab
*Tylenol (Acetaminophen) 325mg/650mg Rectal Supp (Peds Only)
**Tylenol No.3 (acetaminophen/codeine) 325mg/30mg Tab - CIV/ 30 day supply/5 refills max
**Tylenol w/ Codeine** (APAP/codeine) 120mg/12mg Elixir - CIV/30 day supply/5 refills max
**Tylox (acetaminophen/oxycodone) 500mg/5mg Cap
CII/30 day supply/no refills
*Ultram (Tramadol) 50mg Tab (Only a 30 day supply)
Urecholine (Bethanechol) 25mg Tab
Urocit-K (Potassium citrate) 10mg Tab
Vagifem (Estradiol) 10mcg Tab
Valisone (Betamethasone valerate) 0.1% Cr
Valisone (Betamethasone valerate) 0.1% Sol 60ml Bt
**Valium (diazepam) 5mg Tab
CIV/30 day supply/5 refills max
Valtrex (Valacyclovir HCL) 500mg , 1000mg Tab
Vasodilan (Isoxsuprine) 10mg Tab
Vectical (Calcitriol) 3mcg top oint
Vermox (Mebendazole) 100mg Chewable Tab
Vexol (Rimexolone) 1% Sol 5ml
Vibramycin (Doxycycline) 50mg, 100mg Cap
9
**Vicodin (APAP/hydrocodone) 500mg/5mg & 750/7.5 Tab –
CIII/30 day supply/ 5 refills max
**Vicoprofen (hydrocodone/ibuprofen) 7.5mg/200mg Tab
Victoza (Liraglutide) 6mg/ml inj pen
Vigamox (Moxifloxacin) Ophthalmic Drops
*Viroptic (Trifluridine) 1% Ophthalmic Sol 10ml
Visquen (Pindolol) 5, 10 mg Tab
Vistaril (Hydroxyzine Pamoate) 25mg, 50mg Cap
Vitamin B Complex with Vit C
Vitamin B-1 100mg (Thiamine) Tab
Vitamin B-6 (Pyridoxine) Tab
Vitamin B-6 – 50mg Tab
Vitamin B-12 (Cyanocobalamin) 1000mcg Tab
Vitamin B-12 (Cyanocobalamin) 1000mcg /ml
Vitamin D (calciferol) 1.25mg Cap
Vitamin D (Cholecalciferol) 400 units
Vitamin K (Phytonadione) 5mg Tab
Voltaren (Diclofenac sodium) 75mg Tab
Voltaren gel 1% (Diclofenac sodium)
VoSol (Acetic acid) 2% Otic Sol 10ml
VoSol HC (Acetic acid/hydrocortisone) Otic Sol 10ml
Vytorin (Ezetimibe/simvastatin) 10/10mg, 10/20mg,
10/40mg.10/80mg Tab
Wellbutrin (Bupropion) 75mg, 100mg Tab
Wellbutrin SR (Bupropion) 100mg, 150mg, 200mg Tab
Wellbutrin XL (Bupropion XL) 150mg, 300mg Tab
Wellcovorin (Leucovorin) 5mg Tab
Westcort (Hydrocortisone valerate) 0.2% Cr / oint 45gm
Xalatan (Latanoprost) 0.005% Ophthalmic Sol 2.5ml Bt
**Xanax (Alprazolam) 0.25mg, 0.5mg & 1mg Tab
CIV/30 day supply/ 5 refiil max
Xopenex HFA Inh (Levalbuterol) 15 gm
Xopenex (Levalbuterol) 0.31mg/3ml inh sol 28/box
Xopenex (Levalbuterol) 1.25mg/3ml inh sol 28 box
Xopenex (Levalbuterol) 0.63mg/3ml inh sol 28 box
Xylocaine (Llidocaine) 2% Jelly 30gm Tube, 5% Oint 30gm
Xylocaine (Viscous lidocaine) 2% Liquid
Yasmin (Drospirenone/ethinyl estradiol) 3mg/30mcg Tab 28 ds
Yaz (Drospirenone/ethinyl estradiol) 3mg/20mcg Tab 28 ds
Zanaflex (Tizanidine) 2mg, 4mg tab
Zantac (Ranitidine) 150mg Tab, 15mg/ml Syrup
Zarontin (Ethosuximide) 250mg Cap, 250 mg/5ml Syrup
Zaroxolyn (Metolazone) 2.5mg & 5mg Tab
Zestril (Lisinopril) 2.5, 5, 10, 20, 30mg & 40mg Tab
Zestoretic (Hydrochlorothiazide/lisinopril) All strengths
Zetia (Ezetimibe) 10mg Tab
Zirgan (Ganciclovir) ( 0.15% opth gel
Zithromax (Azithromycin) 200mg/5ml & 1gm Susp,
250mg , 500mg Tab, Z-Pak
Zithromax (Azithromycin) 100mg/5ml Susp 15ml syrup
Zocor (Simvastatin) 5mg, 10mg, 20mg, 40mg
& 80mg Tab
*Zofran (Ondansetron) 4, 8mg Tab
*Zofran ODT 4mg, 8mg - 60 Tabs/30 ds/180 Tabs/ 90 ds
Zoladex (Goserelin) 3.6mg & 10.8mg Inj
Zoloft (Sertraline) 25mg, 50mg & 100mg Tab;
20mg/ml conc
Zomig (Zolmitriptan) 2.5, 5mg Tab – limit 12 boxes/90ds
Zomig ODT (Zolmitriptan odt) 2.5, 5mg Tab
limit 12 boxes/90ds
Zostrix (Capaicin) crm 2oz
Zovirax (Acyclovir) 200mg Cap and /400mg, 800mg Tab
Zovirax (Acyclovir) 5% oint, cream
Zovirax (Acyclovir) 200mg/5ml Suspension
Zyloprim (Allopurinol) 100mg & 300mg Tab
Zylet 0.3%-0.5% opht drops susp
Zyrtec (Cetirizine) 5 mg, 10mg Tab ,5mg tbch, 5mg/5ml syrup
Zyprexa (Olanzapine) 2.5, 5, 10, 15mg Tab
Updated: Jul 2011
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